“If all of this stuff about systems and operations management is known about, why isn’t the NHS great?”

1. “If all of this stuff about systems and operations management is known about, why isn’t the NHS great?” Tuesday 12thNovember 2013 Dr Nathan Proudlove, Manchester Business School, University of Manchester nathan.proudlove@mbs.ac.uk v1.1 12 Nov 2013

2. Healthcare Transformation in the NHS • Observations from the NHS… • WEST, DH, MA, NHSI, MTS, Clinical Fellows, Med. Lead. in Practice, etc… • Are systems thinking & operations management principles known about in the NHS? • widely? deeply? • Where are we with dissemination & capability building? • Persistent Barriers to Transformation • Rays of Hope: Some (apparent) major success stories • Salford • TEWV • So….?

3. Are systems thinking & operations management principles known about in the NHS? They should be! • Deming, Toyota / leanetc, Institute for Healthcare Improvement, NHSModernisation Agency, NHS Institute for Innovations & Improvementetc • ‘inside’ innovators & thinkers – e.g. Simon Dodds, Heart of England : 3 Wins, FISH, Imp Sci blog BUT • in practice? • Management capability? • “healthcare is the one area of the economy in which management is seen as a cost rather than a value adding activity”[Nigel Edwards, HSJ 30 June 2011] • MA was “a brief flowering of a movement that, while it had faults, could have reversed this.” “shameful” that it was closed [Nigel Edwards HSJ 30 June 2011] • Continuing drift: ‘administration’  ‘management’  ‘leadership’ • Now NHS LeadershipAcademy • widespread & persistent poor practice - understanding & use of • ‘evidence’, data, operations principles, improvement approaches [Nigel Edwards MTS Sept 2011]

4. Where are we with dissemination/capability building? • NHS Improving Quality • Focus on Outcomes Framework • driven by CCGs? • Capability building? • NHS Leadership Academy • Edward Jenner, Mary Seacole, Elizabeth Garrett Anderson, Nye Bevan, Top Leaders • Medical training • Productives Series, Advancing Quality etc • Bits of lean inside • Compliance? • but “don’t copy examples” – Deming, Ohno, Seddon • “”have a theory, understand your own system””!

5. Persistent Barriers to Transformation Structures? • Organisational silos: not really grasped “customers”: little patient-centred organisational design • Too big to be agile, too small to develop innovative business models [Nigel Edwards] • Very diverse improvement: culture, seriousness, approaches • Limited support, critical mass for service improvement Politics & politics? • short time horizons (initiatives & leaders: 2 years/5 years life expectancy: fads, change fatigue) • evidence-lite, central direction, ‘one-size fits all’, lack of evolution & acceptance of local variation • Defensive, bullying - ‘good news machine’, learning from Complaints? • no ‘honest failure’ [Chris Ham, also Ackoff, Edwards etc] • no culture of experimentation: fail early, fail small, fail often! Embeddedpoor operational practice? • short-termism, firefighting, poor/broken mental models • lack of accountability, too many 2nd chances? • lack of systems & data driven thinking (e.g. Bristol, Shipman) Cost OR quality? It’s too complicated, overwhelming?

6. Rays of Hope 1 : Salford Royal Building a deep culture • CE+ in place for 11 years; back-to-the-floor every month • Clinical directors = separate contract inc.Quality Improvement, peer pressure • Long support from IHI • Focus on Quality • Started with bed sores, hospital acquired infections • Aim to be a High Reliability Organisation • Deference to expertise, ‘Code Red’ – everyone’s responsibility, ward-round checklists • Method! : Model for Improvement + Have a range of approaches in the toolkit (Lean, Clinical Microsystems) • Data!: • SPC (inc. Board dashboard), process mapping, driver diagrams etc • Real-time IS, EPR • Lesson: be reluctant to simplify to soon Top acute on staff satisfaction… • Inc. Clinicians?! • Tours… Quality  … Costs  ? Also Intermountain Healthcare in US (PBS film sometimes available on the internet)

7. Rays of Hope 2 : Tees, Esk & Wear Valleys Taking it seriously… • Massive drive, support and enthusiasm from Board & clinical directors • Focus 50:50 quality & efficiency (?) • Totalityof Lean approach, inc. terminology… • Toyota  Virginia Mason  TEWV • Systematicuse of the “tools and techniques” • measurement + feedback • Not an add-on: part of everything they do • “Seems to be what we do around here”! • Development of staff compact, trust Key methodology (but not a panacea) for achieving vision and strategic goals: • 5-day cycle (Rapid Process Development Workshop) • Then becomes part of practice for everyone • Staff empowered to start own PDSAs awards (2012), top 5% staff satisfaction, 2nd on reference costs; a long way to go! • Quality  Efficiency  … Costs  • buying back PFI facilities? • Trips to Seattle!

8. So… Real leadership: • Constancy of purpose • Taking it seriously • Personal engagement (bottom-to-top) • Translation of goals & ‘3 Wins’ (enabling “joy in work” [Deming, also Christensen]) • Patients: quality & experience: aspirations, wants & needs • Staff: intrinsic motivators; removing threats, demotivators[Deming], ‘niggles’ [Dodds] • Organisation: costs as outputs: consequences of system performance (sandcone model) Competent, valued management: • Data is part of everyone’s day job • Data  information  wisdom [Ackoff] , reflective learning • Amethod • Systems thinking: purpose, metrics, method … • Accept the complexity • Some core tools: processes mapping, SPC, visual management etc • Fast & disciplinedexperimentation (e.g. PDSA) & small, quick honest failures  learning • About causal models, data & evidence-backed: ‘improvement science’

9. Some accessible resources… Dodds, S (2013) , The Improvement Science Blog www.saasoft.com/blog/ Also his book about his early inferences of operations principles and redesigns of his own service, for which he won the first NHS Innovation Prize, is available for the cost of printing… DoddsS (2007). Three Wins: Service improvement using value stream design. lulu.com: 978-1-84753-631-0 www.amazon.co.uk/Three-Wins-Service-Improvement-Stream/dp/184753631X Seddon J (2008). Systems thinking and…designing and managing services.Triarchy Press:http://webbrain.com/attach?brain=20DD893D-19A2-04E3-950C-3DA53FAB3BE1&attach=273&type=1 This is based on his book, which contains many examples of application in the UK public sector: SeddonJ (2008). Systems thinking in the public sector.Triarchy Press:Axminster, UK.